Provider Demographics
NPI:1184842288
Name:POLEN, DENINE LYNN (DNP)
Entity Type:Individual
Prefix:MS
First Name:DENINE
Middle Name:LYNN
Last Name:POLEN
Suffix:
Gender:F
Credentials:DNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 944
Mailing Address - Street 2:
Mailing Address - City:MARGARETVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12455-0944
Mailing Address - Country:US
Mailing Address - Phone:917-680-2621
Mailing Address - Fax:866-573-0758
Practice Address - Street 1:816 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARGARETVILLE
Practice Address - State:NY
Practice Address - Zip Code:12455-8028
Practice Address - Country:US
Practice Address - Phone:917-680-2621
Practice Address - Fax:866-573-0758
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2021-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335170363LF0000X
NY33335170363LF0000X
NY33 335170363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03133231Medicaid